What is the next step in managing a pregnant patient at 33 weeks gestation with painless vaginal bleeding, ongoing bleeding, and hypotension (low blood pressure)?

Immediate Cesarean Section is Required

In a patient at 33 weeks gestation with painless vaginal bleeding, ongoing active hemorrhage, and hypotension (BP 90/60), immediate cesarean delivery is the next step. This clinical presentation is most consistent with placenta previa or placental abruption causing hemodynamic instability, which mandates urgent delivery to save both mother and fetus. 1

Critical Management Priorities

Immediate Stabilization While Preparing for Delivery

• Secure two large-bore (14-16 gauge) intravenous lines immediately for aggressive fluid resuscitation and blood product administration. 2

• Activate massive transfusion protocol without waiting for laboratory results—transfuse packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio when managing acute obstetric hemorrhage. 3

• Maintain left lateral tilt or manual uterine displacement to prevent aortocaval compression and optimize cardiac output, as supine positioning at 33 weeks significantly reduces venous return and placental perfusion. 2

• Administer supplemental oxygen to maintain maternal oxygen saturation >95% for adequate fetal oxygenation. 2

Why Cesarean Section Takes Priority Over Other Options

Option A (Observation) is contraindicated because the patient has ongoing active bleeding with hypotension—this represents hemodynamic instability requiring immediate intervention, not expectant management. 4

Option B (IM Steroids and delivery) is incorrect because while delivery is necessary, delaying for intramuscular steroid administration in a hemodynamically unstable patient is inappropriate. Steroids require 24-48 hours for fetal lung maturity benefit, and this patient cannot wait. 2

Option C (Transfuse Blood alone) is insufficient as the sole intervention. While blood transfusion is essential and should be initiated immediately, it does not address the ongoing source of hemorrhage. In obstetric hemorrhage with hemodynamic instability, definitive management requires delivery. 3, 4

Option D (Cesarean Section) is correct because it simultaneously addresses maternal hemodynamic instability and removes the bleeding source while potentially salvaging a viable fetus at 33 weeks. 2

Clinical Reasoning for This Scenario

Differential Diagnosis

• Placenta previa is the most likely diagnosis given painless vaginal bleeding at 33 weeks, affecting approximately 1 in 200 pregnancies at delivery. 5

• Placental abruption must also be considered, though it typically presents with abdominal pain; however, abruption can cause rapid hemodynamic deterioration and ultrasound misses up to 50% of cases. 5, 1

Why Immediate Delivery is Mandatory

• Hypotension (BP 90/60) with ongoing bleeding indicates significant blood loss that has overcome the pregnant patient's physiologic hypervolemia—this represents decompensated shock requiring urgent intervention. 4

• At 33 weeks gestation, the fetus is viable (≥23 weeks), making immediate delivery both feasible and necessary to prevent maternal exsanguination and fetal demise. 2

• Continued bleeding with hemodynamic instability will not resolve without delivery when the source is placental, as the placenta cannot be accessed or controlled without delivering the fetus first. 3

Critical Pitfalls to Avoid

• Never perform digital vaginal examination before ultrasound confirmation in a patient with suspected placenta previa, as this can precipitate catastrophic hemorrhage. However, in this hemodynamically unstable patient, there is no time for ultrasound—proceed directly to cesarean section. 5, 1

• Do not delay delivery for diagnostic imaging when the patient is hemodynamically unstable with ongoing hemorrhage. Stabilization and delivery take absolute priority. 2

• Avoid vasopressors until after aggressive fluid and blood product resuscitation, as vasopressors reduce uteroplacental perfusion and should only be used for intractable hypotension unresponsive to volume replacement. 2

• Keep the patient warm (body temperature >36°C) as hypothermia impairs clotting factor function and worsens coagulopathy in massive hemorrhage. 3

Multidisciplinary Coordination

• Alert anesthesia, neonatology, and blood bank immediately as this patient requires general anesthesia, neonatal resuscitation team at delivery, and ongoing massive transfusion support. 3

• Obtain baseline coagulation studies including fibrinogen before surgery if time permits, but do not delay delivery for laboratory results. 2

• Plan for potential hysterectomy if bleeding cannot be controlled after delivery, though uterotonic agents and conservative measures should be attempted first. 4